Reduction mammaplasty and gynecomastia

Patients with mammary hypertrophy can present with a variety of symptoms.

Physical complaints include neck and back pain, shoulder grooving from bra straps indenting the skin, headaches, difficulty finding well-fitted clothes and limited ability to exercise, intertriginous skin maceration, and rashes.

Psychosocial issues include embarrassment, especially teenagers and elderly women.

Though the symptomatic improvement of patients suffering from mammary hypertrophy is the primary goal of reduction mammaplasty, there is another goal that is nearly as equally important – creating a more aesthetic breast.

Spear describes the reduction mammaplasty as “the clearest example of the interface between reconstructive plastic surgery and aesthetic plastic surgery”.

This chapter seeks to demonstrate the most popular techniques for reduction mammaplasty. The key point for choosing the reduction mammoplasty technique is finding what works for you, the surgeon, and what gives your patients the best results.

As breast reduction procedures have evolved, certain goals have been consistent:

• Aesthetic, natural breast shape.

• Maintenance of shape long term.

• Reducing scar length.

Like macromastia, gynecomastia can result in many of the same symptoms, complaints, and anatomical concerns.

Careful consideration of the factors that compel patients to seek reduction mammaplasty are key in the plastic surgeon's assessment of patients with mammary hypertrophy.

A thorough history of symptoms associated with mammary hyperplasia should be recorded.

A personal and family history of breast disease and surgery should be recorded, and the results of any testing, such as mammography, breast ultrasound or MRI, and BRCA testing, should be obtained prior to surgical intervention.

In addition to screening, a thorough physical examination should be performed as well, noting any relevant points of the patient's general condition as well as an examination of the breast. In the United States, only some breast reduction procedures are considered medically necessary.

Such salient general points relate to the patient's height, weight, and habitus, and these measures are often mandatory for insurers to calculate the amount of breast tissue they require for the reduction procedure to be covered.

This amount of tissue can, however, vary from state to state and from insurer to insurer.

A focal breast exam is mandatory as well, evaluating for any masses of the breast, axilla, and supra- and infraclavicular fossae. The nipple–areolar complex should be assessed for changes or discharge, as well as its preoperative sensitivity.

Some women have decreased sensitivity due to prior surgery, but often there is decreased sensitivity due to the excess weight of the breast causing traction injury to the cutaneous innervation of the nipple–areolar complex.

The skin of the breast should be scrutinized to assess for stigmata of previous operations or physiologic changes, such as scars or striae, which should be pointed out to the patient preoperatively.

Finally, shape and symmetry of the breasts preoperatively must also be assessed and pointed out to the patient, especially in cases of very large breasts, because some degree of asymmetry will virtually always remain postoperatively.

Breast measurements, such as the sternal notch to nipple distance, the nipple to inframammary fold distance, and the nipple to nipple distance, must be documented preoperatively.